IMPORTANT INFORMATION:

(1)

NEW HAMPSHIRE

Coverage under this Plan is under the jurisdiction of the New Hampshire Insurance Commissioner.

IMPORTANT INFORMATION: This policy reflects the known requirements for compliance

under The Affordable Care Act as passed on March 23, 2010. As additional guidance

is forthcoming from the US Department of Health and Human Services, and the New

Hampshire Insurance Department, those changes will be incorporated into your health

insurance policy.

This Schedule of Benefits summarizes your Benefits under the HPHC Insurance Company PPO (the

Plan) and states the Member Cost Sharing amounts that you must pay for Covered Benefits.

However, it is only a summary of your benefits. Please see your Benefit Handbook and Prescription

Drug Brochure (if you have the Plan’s outpatient pharmacy coverage) for detailed information on

benefits covered by the Plan and the terms and conditions of coverage.

There are two levels of coverage: In-Network and Out-of-Network.

•

In-Network

coverage applies when you use a Plan Provider for Covered Benefits. When using

Plan Providers, coverage is based on the contracted rate between HPHC and the Provider.

•

Out-of-Network

coverage applies when you use a Non-Plan Provider for Covered Benefits.

When using Non-Plan Providers, the Plan pays only a percentage of the cost of the care you

receive up to the Usual, Customary and Reasonable Charges for the service. In most cases,

this will be higher than the HPHC contracted rate. If a Non-Plan Provider charges any amount

in excess of the Usual, Customary and Reasonable Charge, you are responsible for the excess

amount. Please refer to section I.F. Member Cost Sharing in your Benefit Handbook for

additional information about Out-of-Network Charges in Excess of the Usual, Customary

and Reasonable Charge.

You always have coverage for care in a Medical Emergency. In a Medical Emergency, you should

go to the nearest emergency facility or call 911 or other local emergency number. Your emergency

room Member Cost Sharing is listed below under the heading “Emergency Room Care.”

Member Responsibility for Notification and Prior Approval

Members must contact HPHC for coverage of a number of services. These are listed below.

Mental Health and Drug and Alcohol Rehabilitation Services.

. Prior Approval must be

obtained before receiving certain mental health and drug and alcohol rehabilitation services from

Non-Plan Providers. Please refer to our internet site,

www.harvardpilgrim.org

, or contact the

Member Services Department at

1-888-333-4742

for a list of services. To obtain Prior Approval

for mental health and drug and alcohol rehabilitation services, please call the Behavioral Health

Access Center at

1-888-777-4742

.

Medical Services.

Members are required to notify HPHC before the start of any planned

inpatient admission to a Non-Plan medical facility. Members are also required to obtain Prior

Approval from HPHC for certain services. Before you receive services from a Non-Plan Provider,

please refer to our Internet site,

www.harvardpilgrim.org

, or contact the Member Services

Department at

1-888-333-4742

for a list of Out-of-Network services that require Prior Approval.

If you do not provide notification or obtain Prior Approval when required, you will be responsible

for paying the Penalty amount stated in this Schedule of Benefits in addition to any applicable

Member Cost Sharing. No coverage will be provided if HPHC determines that the service is not

Medically Necessary, and you will be responsible for the entire cost of the service.

(2)

condition. If notice is given to HPHC by an attending emergency physician, no further notification

is required. However, if notification is not received when the Member's condition permits it, the

Member is responsible for the Penalty amount stated in this Schedule of Benefits. Please call

1-800-708-4414

to notify us of an emergency admission to a Non-Plan facility.

Clinical Review Criteria

We use clinical review criteria to evaluate whether certain services or procedures are Medically

Necessary for a Member’s care. Members or their practitioners may obtain a copy of our clinical

review criteria applicable to a service or procedure for which coverage is requested. Clinical

review criteria may be obtained by calling

1-888-888-4742 ext. 38723

.

DEDUCTIBLE

A Deductible is a specific dollar amount that is payable by the Member for Covered Benefits

received each Plan Year before any benefits subject to the Deductible are payable by the Plan. If a

family Deductible applies, it is met when any combination of Members in a covered family incur

expenses for services to which the Deductible applies.

Not all services under this Plan are subject to the Deductible. You may have different Deductibles

that apply to different Covered Benefits under your Plan. Deductible amounts are incurred as of

the date of service. Your Plan Deductible amounts are listed below.

Your Plan has both an individual Deductible and a family Deductible. However, please note that a

Family Deductible only applies if you have Family Coverage. Unless a family Deductible applies,

you are responsible for the individual Deductible for covered services each Plan Year. If you are a

Member with a family Deductible, your Deductible can be satisfied in one of two ways:

a.

If a Member of a covered family meets an individual Deductible, then services for that

Member that are subject to that Deductible are covered by the Plan for the remainder of

the Plan Year.

b.

If any number of Members in a covered family collectively meet the family Deductible, then

all Members of the covered family receive coverage for services subject to that Deductible for

the remainder of the Plan Year.

Your Plan has separate Deductibles that apply to your In-Network and Out-of-Network benefits.

You must meet the In-Network Deductible before In-Network services are covered by the Plan.

You must meet the Out-of-Network Deductible before Out-of-Network services are covered by

the Plan.

Any eligible expenses you incur toward the Deductible in a Plan Year apply to

both

the In-Network

and the Out-of-Network Deductibles. Once you meet the In-Network Deductible, which is usually

the lower of the two, you may begin to receive coverage for In-Network services. If you later

meet the Out-of-Network Deductible you may also receive coverage for Out-of-Network services.

Once a Deductible is met, coverage by the Plan is subject to any other Member Cost Sharing

that may apply.

Your Covered Benefits are administered on a Plan Year basis. Your Plan Year begins on your

Employer’s Anniversary Date. Please see your Benefit Handbook for more details. If you do not

know your Employer’s Anniversary Date, please contact your Employer’s benefits office or call the

Member Services Department at

1-888-333-4742

.

(3)

In-Network Coinsurance and Copaymentsj

See Covered Benefits below

Out-of-Network Coinsurance and Copaymentsj

See Covered Benefits below

In-Network Deductiblej

$1,000 per Member per Plan Year $3,000 per family per Plan Year

Out-of-Network Deductiblej

In-Network Durable Medical Equipment Deductiblej

$100 per Member per Plan Year

Out-of-Pocket Maximum j

– Includes all In-Network and Out-of-Network Member Cost Sharing except charges for outpatient prescription drugs. Any charges above the Usual, Customary and Reasonable Charge and any penalty for failure to receive Prior Approval when using Non-Plan Providers do not apply to the Out-of-Pocket Maximum.

Out-of-Network Penalty Payment for failure to obtain Prior Approvalj

You must notify HPHC in advance of any planned inpatient admission to a Non-Plan Medical Facility. You are also required to obtain Prior Approval from HPHC before receiving certain services from a Non-Plan Provider. If you do not provide notification or get Prior Approval for these services, you are responsible for 50% of the benefit that would have otherwise been payable or $500 whichever is less. This Penalty charge is in addition to any Member Cost Sharing amounts and does not count toward the Deductible or Out-of-Pocket Maximum. Please see sectionI.G. NOTIFICATION AND PRIOR APPROVALin your handbook for more information.

Pre-existing Condition Limitationj

None

Benefit In-Network

Plan Providers

Member Cost Sharing

Out-of-Network Non-Plan Providers Member Cost Sharing Ambulance Transportj

– Emergency ambulance transport Deductible, then 20% Coinsurance Same as In-Network – Non-emergency ambulance transport Deductible, then 20% Coinsurance Deductible, then 40% Coinsurance

(4)

Autism Spectrum Disorders Treatmentj

– Applied behavior analysis – limited to $36,000 per Plan Year for Members through the age of 12 and $27,000 for Members age 13 to age 21

$20 Copayment per visit Deductible, then 40% Coinsurance

– All other benefits are covered as stated in this Schedule of Benefits – No benefit limits apply to physical therapy, occupational therapy or speech therapy for the treatment of autism spectrum disorders

Your Member Cost Sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see “Physician and Other Professional Services.” For services provided by a speech therapist, physical therapist and occupational therapist see "Rehabilitation Therapy – Outpatient.”

Bariatric Surgeryj

Your Member Cost Sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see “Physician and Other Professional Services.” For inpatient hospital care, see “Hospital – Inpatient Services.”

Chiropractic Carej

– Limited to 12 visits per Plan Year $20 Copayment per visit Deductible, then 40% Coinsurance

Clinical Trialsj

Dental Servicesj

– Emergency Dental Care Your Member Cost Sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided in a dentist’s office, see “Physician and Other Professional Services.” For services provided in a hospital emergency room, see “Emergency Room Care.”

– Outpatient Surgery Expenses for Dental Care

Your Member Cost Sharing will depend upon the types of services provided, as listed in this Schedule of Benefits. For example, for services provided by a physician, see “Physician and Other Professional Services.” For day surgery, see "Surgery –Outpatient."

Diabetes Services and Suppliesj

– Self management and training/diabetic eye examinations/foot care

– Diabetes equipment and supplies Member Cost Sharing does not apply to blood glucose monitors or insulin pumps (including supplies) and infusion devices.

Durable Medical Equipment Deductible, then 20% Coinsurance

Deductible, then 40% Coinsurance

(5)

Diabetes Services and Supplies (Continued)

– Pharmacy supplies Subject to the applicable pharmacy Member Cost Sharing listed on your ID Card. If your Plan does not include coverage for outpatient prescription drugs, then coverage is subject to the lower of the pharmacy’s retail price or a Copayment of $5 for Tier 1 drugs or supplies, $10 for Tier 2 drugs or supplies and $25 for Tier 3 drugs or supplies.

Subject to the applicable pharmacy Member Cost Sharing listed on your ID Card. If your Plan does not include coverage for outpatient prescription drugs, then coverage is subject to the lower of the pharmacy’s retail price or a Copayment of $5 for Tier 1 drugs or supplies, $10 for Tier 2 drugs or supplies and $25 for Tier 3 drugs or supplies. For information on the drug tiers, please visit our website atwww.harvardpilgrim.org/ membersand select "pharmacy/drug tier look up" contact the Member Services Department at1-888-333-4742.

Dialysisj

– Dialysis services Deductible, then no charge Deductible, then 40% Coinsurance

– Installation of home equipment is covered up to $300 in a Member's lifetime

No charge Deductible, then 40%

Coinsurance

Durable Medical Equipment and Prosthetic Devicesj

Early Interventionj

– Limited to $3,200 per Plan Year, up to $9,600 per lifetime

Emergency Admissionj

Deductible, then no charge Same as In-Network

Emergency Room Carej

Deductible, then $100 Copayment per visit This Copayment is waived if admitted to the hospital directly from the emergency room.

Same as In-Network

Family Planning Servicesj

Hearing Aids j

– Limited to $1,500 per hearing aid every 60 months, for each hearing impaired ear

Coinsurance

Home Health Carej

(6)

Hospice Servicesj

No charge for outpatient services

For inpatient hospital care, see “Hospital – Inpatient Services.”

Hospital – Inpatient Servicesj

House Callsj

Human Organ Transplant Servicesj

Infertility Servicesj

The Plan covers the following diagnostic services for infertility:

– Consultation – Evaluation – Laboratory tests

Please Note: The Plan does not cover infertility treatment.

Laboratory and Radiology Servicesj

– Laboratory and x-rays Deductible, then no charge Deductible, then 40% Coinsurance

– High end radiology (CT scans, PET scans, MRI and MRA, and nuclear medicine services)

No Member Cost Sharing applies to certain preventive care services. See “Preventive Services and Tests,” below.

Low Protein Foodsj

– Limited to $1,800 per Member per Plan Year

Coinsurance

Maternity Carej

– Routine outpatient prenatal and postpartum care

(7)

Maternity Care (Continued)

– Preventive services and screenings including: counseling about alcohol and tobacco use, services to promote breastfeeding, routine urinalysis and screenings for the following: asymptomatic bacteriuria; hepatitis B infection; HIV and screenings for STDs (chlamydia, gonorrhea and syphilis); iron deficiency anemia; and Rh (D) incompatibility. Please see “Preventive Services and Tests,” below, for additional services and tests covered with no Member Cost Sharing.

Coinsurance

Please Note: Routine prenatal and postpartum care is usually received and billed from the same Provider as a single or bundled service. Different Member Cost Sharing may apply to any specialized or non-routine service that is billed separately from your routine outpatient prenatal and postpartum care. For example, for services provided by another physician or specialist, see “Physician and Other Professional Services” for your applicable Member Cost Sharing. Please see your Benefit Handbook for more information on maternity care.

– Routine nursery care for the newborn, including prophylactic medication to prevent gonorrhea and screenings for the following: hearing loss; congenital

hypothyroidism; phenylketonuria (PKU); and sickle cell disease

Coinsurance

– Hospital inpatient services Deductible, then 20% Coinsurance

Medical Formulasj

Coinsurance

Mental Health and Drug and Alcohol Rehabilitation Servicesj

Please Note: No day or visit limits apply to mental health treatment for Serious Mental Illnesses as described in yourBenefit Handbook.

Inpatient Services

– Mental health services in a licensed general hospital – unlimited – Mental health services in a

psychiatric hospital — limited to 30 days per Plan Year

– Drug and alcohol rehabilitation services — limited to 30 days per Plan Year

– Detoxification services

20% Coinsurance 40% Coinsurance

(8)

Mental Health and Drug and Alcohol Rehabilitation Services (Continued)

– Partial hospitalization for mental health services - limited to 60 days per Member per Plan Year

– Partial hospitalization for drug and alcohol rehabilitation services - limited to 60 days per Member per Plan Year

20% Coinsurance 40% Coinsurance

Please Note: Each partial hospitalization day counts as one-half of an inpatient day and is deducted from the limit available for inpatient services.

Outpatient Services

– Mental health services — limited to 20 visits or $3,000 per Plan Year whichever is greater

Individual therapy: $20 Copayment per visit Group therapy: $10 Copayment per visit

40% Coinsurance

– Drug and alcohol rehabilitation services — limited to 20 visits per Plan Year

Individual therapy: $20 Copayment per visit Group therapy: $10 Copayment per visit

40% Coinsurance

– Detoxification services $20 Copayment per visit 40% Coinsurance – Medication management $20 Copayment per visit 40% Coinsurance – Psychological testing $20 Copayment per visit Deductible, then 40%

Coinsurance

Ostomy Suppliesj

Physician and Other Professional Services (This includes all covered medical professionals unless otherwise stated in this Schedule of Benefits)j

– Routine examinations for preventive care, including immunizations

No Member Cost Sharing applies to certain preventive care services see “Preventive Services and Tests,” below.

Coinsurance

– Sickness and injury care $20 Copayment per visit Deductible, then 40% Coinsurance

– Administration of allergy

injections $5 Copayment per visit

(9)

Preventive Services and Testsj

Limited to the following select preventive laboratory and pathology tests and screenings as defined by federal law:

Coinsurance

– Abdominal aortic aneurysm screening (for males 65-75 one time only, if ever smoked)

– Alcohol misuse screening and counseling (primary care visits only)

– Aspirin for the prevention of heart disease (primary care counseling only) – Autism screening (for

children at 18 and 24 months of age – primary care visits only)

– Behavioral assessments (developmental

surveillance, for children of all ages – primary care visits only)

– Blood pressure screening – Breast cancer

chemoprevention counseling (only for women at high risk for Breast Cancer and low risk for adverse effects of chemoprevention) – Breast cancer screening,

including mammograms and counseling for genetic susceptibility screening

– Cervical cancer screening, including pap smears – Cholesterol screening (for

adults only) – Colorectal cancer

screening, including colonoscopy,

sigmoidoscopy and fecal occult blood test

– Dental caries prevention -oral fluoride (for children to age 5 only)

Note: Coverage for fluoride is only provided if your Plan includes outpatient pharmacy coverage.

– Depression screening (primary care visits only) – Diabetes screenings – Diet counseling

– Dyslipidemia screening (for children at high risk for higher lipid levels) – Folic acid supplements

(women planning or capable of pregnancy only)

Note: Coverage for folic acid is only provided if your Plan includes outpatient pharmacy coverage.

– Hemoglobin A1c – Hepatitis B testing

– HIV screening

– Immunizations, including flu shots (for children and adults as appropriate) – Iron deficiency prevention

(primary care counseling for children age 6 to 12 months only)

– Lead screening (for children at risk) – Microalbuminuria test – Obesity screening

– Osteoporosis screening (to begin at age 60 for women at increased risk) – Ovarian cancer susceptibility screening – Sexually transmitted diseases STDs - screenings and counseling

– Tobacco use counseling (primary care visits only) – Total cholesterol tests – Tuberculosis skin testing – Vision screening (children

to age 5 only)

Please see the Maternity Care benefit for additional services and tests covered with no Member Cost Sharing.

Under federal law the list of preventive services and tests covered above may change periodically based on the recommendations of the following agencies:

a. Grade “A” and “B” recommendations of the United States Preventive Services Task Force;

b. With respect to immunizations, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and

c. With respect to services for woman, infants, children and adolescents, the Health Resources and Services Administration.

Information on the recommendations of these agencies may be found on the web site of the US Department of Health and Human Services at:

http://www.healthcare.gov/center/regulations/prevention/recommendations.html.

Harvard Pilgrim will add or delete services from this benefit for preventive services and tests in accordance with changes in the recommendations of the agencies listed above. You can find a list of the current recommendations for preventive care on Harvard Pilgrim’s web site atwww.harvardpilgrim.org.

(10)

Reconstructive Surgeryj

Rehabilitation Hospital Carej

– Limited to 100 days per Plan Year – Day limits combined with Skilled

Nursing Facility Care Services

Rehabilitation Therapy - Outpatientj

– Cardiac Rehabilitation

– Pulmonary Rehabilitation Therapy – Occupational, physical, and

speech therapies - limited to 60 visits combined per Plan Year

Scopic Procedures - Outpatient Diagnostic and Therapeuticj

– Colonoscopy, endoscopy and sigmoidoscopy

No Member Cost Sharing applies to certain preventive care services. See “Preventive Services and Tests,” listed above.

Coinsurance

Skilled Nursing Facility Care Servicesj

– Limited to 100 days per Plan Year – Day limits combined with

Rehabilitation Hospital Care

Deductible, then 20% Coinsurance Deductible, then 40% Coinsurance Surgery — Outpatientj Deductible, then 20% Coinsurance Deductible, then 40% Coinsurance Telemedicinej

– Outpatient and Inpatient Telemedicine services

Temporomandibular Joint Dysfunction Services (medical treatment only)j

Urgent Care Center Servicesj

Deductible, then $50 Copayment per visit

(11)

Vision Servicesj

– Routine eye examinations limited

to 1 per Plan Year $20 Copayment per visit

– Vision hardware for special conditions (see your Benefit Handbook for details)

Coinsurance

Voluntary Sterilizationj

Deductible, then no charge Deductible, then 40% Coinsurance

Voluntary Termination of Pregnancyj

Deductible, then no charge Deductible, then 40% Coinsurance

Wigs and Scalp Hair Prostheses as required by lawj

(12)

The exclusions headings in this section are intended to group together services, treatments, items, or supplies

that fall into a similar category. Actual exclusions appear underneath the headings. A heading does not create,

define, modify, limit or expand an exclusion.

The services listed in the table below are not covered by the Plan:

Exclusion Description

1. Alternative Treatments

[#.] [Acupuncture services][, except when specifically listed as a Covered Benefit

(please see your Schedule of Benefits).]

[#.] [Acupuncture services that are outside the scope of standard acupuncture

treatment[, except when specifically listed as a Covered Benefit (please see your

Schedule of Benefits),] including services for preventive, maintenance, or wellness

care, thermography, hair analysis, heavy metal screening or mineral studies,

massage or soft-tissue techniques, diagnostic services, x-rays or services related

to menstrual cramps.]

[#.] Alternative, holistic or naturopathic services and all procedures, laboratories

and nutritional supplements associated with such treatments.

[#.] Aromatherapy, treatment with crystals and alternative medicine.

[#.] Health resorts, spas, recreational programs, camps, wilderness programs,

outdoor skills programs, relaxation or lifestyle programs, including any services

provided in conjunction with, or as part of such types of programs.

[#.] Massage therapy when performed by anyone other than a licensed

physical therapist, physical therapy assistant, occupational therapist, or certified

occupational therapy assistant.

[#.] Myotherapy.

2. Dental Services

[#.] Dental Care, except the specific dental services listed in this Benefit Handbook

and your Schedule of Benefits.

[#.] All services of a dentist for Temporomandibular Joint Dysfunction (TMD).

[#.] [Extraction of teeth][, except when specifically listed as a Covered Benefit

(please see your Schedule of Benefits).]

[#.] [Preventive dental care for children][, except when specifically listed as a

Covered Benefit (please see your Schedule of Benefits).]

(13)

[#.] Any devices or special equipment needed for sports or occupational purposes.

[#.] Any home adaptations, including, but not limited to home improvements and

home adaptation equipment.

[#.] [Myoelectric and bionic arms and legs][, except when specifically listed as a

Covered Benefit. (Please see your Schedule of Benefits).]

[#.] Non-durable medical equipment, unless used as part of the treatment at a

medical facility or as part of approved home health care services.

[#.] Repair or replacement of durable medical equipment or prosthetic devices as

a result of loss, negligence, willful damage, or theft.

4. Experimental, Unproven or Investigational Services

[#.] Any products or services, including, but not limited to, drugs, devices,

treatments, procedures, and diagnostic tests that are Experimental, Unproven,

or Investigational.

5. Foot Care

[#.] Foot orthotics, except for the treatment of severe diabetic foot disease [or when

specifically listed as a Covered Benefit. (Please see your Schedule of Benefits)].

[#.] Routine foot care. Examples include nail trimming, cutting or debriding and

the cutting or removal of corns and calluses. This exclusion does not apply to

preventive foot care for Members with diabetes.

6. Mental Health Care

[#.] Biofeedback.

[#.] Educational services or testing, except services covered under the benefit for

Early Intervention Services. No benefits are provided: (1) for educational services

intended to enhance educational achievement; (2) to resolve problems of school

performance; or (3) to treat learning disabilities.

[#.] Methadone maintenance.

[#.] Sensory integrative praxis tests.

[#.] Services for any condition with only a “V Code” designation in the Diagnostic

and Statistical Manual of Mental Disorders, which means that the condition is

not attributable to a mental disorder.

[#.] Mental health care that is (1) provided to Members who are confined or

committed to a jail, house of correction, prison, or custodial facility of the

Department of Youth Services; or (2) provided by the Department of Mental

Health.

[#.] Services or supplies for the diagnosis or treatment of mental health and

drug and alcohol rehabilitation services that, in the reasonable judgment of the

Behavioral Health Access Center, are any of the following:

•

Not consistent with prevailing national standards of clinical practice for the

treatment of such conditions.

(14)

•

Typically do not result in outcomes demonstrably better than other available

treatment alternatives that are less intensive or more cost effective.

7. Physical Appearance

[#.] Cosmetic Services, including drugs, devices, treatments and procedures,

except for (1) Cosmetic Services that are incidental to the correction of Physical

Functional Impairment, (2) restorative surgery to repair or restore appearance

damaged by an accidental injury, and (3) post-mastectomy care.

[#.] Hair removal or restoration, including, but not limited to, electrolysis, laser

treatment, transplantation or drug therapy.

[#.] Liposuction or removal of fat deposits considered undesirable.

[#.] Scar or tattoo removal or revision procedures (such as salabrasion,

chemosurgery and other such skin abrasion procedures).

[#.] Skin abrasion procedures performed as a treatment for acne.

[#.] Treatment for skin wrinkles or any treatment to improve the appearance of

the skin.

[#.] Treatment for spider veins.

[#.] Wigs, except as required by law [or when specifically listed as a Covered

Benefit (please see your Schedule of Benefits)].

8. Procedures and Treatments

[#.] [Chiropractic care[, except when specifically listed as a Covered Benefit (please

see your Schedule of Benefits)].]

[#.] [Care by a chiropractor outside the scope of standard chiropractic practice,

including but not limited to, surgery, prescription or dispensing of drugs or

medications, internal examinations, obstetrical practice, or treatment of infections

and diagnostic testing for chiropractic care.]

[#.] Commercial diet plans, weight loss programs and any services in connection

with such plans or programs.

[#.] Gender reassignment surgery and all related drugs and procedures.

[#.] If a service is listed as requiring that it be provided at a Center of Excellence,

no In-Network coverage will be provided under this Handbook if that service is

received from a Provider that has not been designated as a Center of Excellence.

Please see the section

I.D.4. Centers of Excellence

for more information.

[#.] Nutritional or cosmetic therapy using vitamins, minerals or elements, and

other nutrition-based therapy. Examples include supplements, electrolytes, and

foods of any kind (including high protein foods and low carbohydrate foods).

[#.] Physical examinations and testing for insurance, licensing or employment.

[#.] Services for Members who are donors for non-members, except as described

under Human Organ Transplant Services.

(15)

[#.] Charges for services which were provided after the date on which your

membership ends.

[#.] Charges for any products or services, including, but not limited to, professional

fees, medical equipment, drugs, and hospital or other facility charges, that are

related to any care that is not a Covered Benefit under this Handbook.

[#.] Charges for missed appointments.

[#.] Concierge service fees. (See section

I.J. PROVIDER FEES FOR SPECIAL

SERVICES (CONCIERGE SERVICES)

for more information.)

[#.] Inpatient charges after your hospital discharge.

[#.] Provider's charge to file a claim or to transcribe or copy your medical records.

[#.] Services or supplies provided by: (1) anyone related to you by blood, marriage

or adoption, or (2) anyone who ordinarily lives with you.

10. Reproduction

[#.] Any form of Surrogacy or services for a gestational carrier.

[#.] [Birth control drugs, implants and devices that must be purchased at an

outpatient pharmacy, unless your Plan includes outpatient pharmacy coverage.]

[#.] Infertility drugs if a member is not in a Plan authorized cycle of infertility

treatment.

[#.] Infertility drugs, if infertility services are not a Covered Benefit.

[#.] Infertility drugs that must be purchased at an outpatient pharmacy, unless

your Plan includes outpatient pharmacy coverage.

[#.] Infertility treatment for Members who are not medically infertile.

[#][Infertility treatment[, except when specifically listed as a Covered Benefit

(please see your Schedule of Benefits)], including, but not limited to, [therapeutic

donor insemination, including related sperm procurement and banking][,

donor egg procedures, including related egg and inseminated egg procurement,

processing and banking][, assisted hatching][, gamete intrafallopian transfer

(GIFT)][, intra-cytoplasmic sperm injection (ICSI)][, intra-uterine insemination

(IUI)][, in-vitro fertilization (IVF)][, zygote intrafallopian transfer (ZIFT)][,

preimplantation genetic diagnosis (PGD)][, miscrosurgical epididiymal sperm

aspiration (MESA)] [and testicular sperm extraction (TESE)].]

[#.] Reversal of voluntary sterilization (including any services for infertility related

to voluntary sterilization or its reversal).

[#.] [Sperm collection, freezing and storage] [except as described in section

III.

Covered Benefits

,

Infertility Services and Treatment.

][ when infertility treatment is

listed as a covered benefit (please see your Schedule of Benefits).]

[#.] Sperm identification when not Medically Necessary (e.g., gender

identification).

(16)

[#.] [Voluntary sterilization, including tubal ligation and vasectomy][, except when

specifically listed as a Covered Benefit (please see your Schedule of Benefits).]

[#.] [Voluntary termination of pregnancy][, except when specifically listed as a

Covered Benefit (please see your Schedule of Benefits).]

[#.] [Voluntary termination of pregnancy, unless the life of the mother is in danger.]

11. Services Provided Under Another Plan

[#.] Costs for any services for which you are entitled to treatment at government

expense, including military service connected disabilities.

[#.] Costs for services for which payment is required to be made by a Workers'

Compensation plan or an Employer under state or federal law.

12. Telemedicine

[#.] Telemonitoring, telemedicine services involving e-mail, fax, or audio-only

telephone, telemedicine services involving stored images forwarded for future

consultation, i.e. “store and forward” telecommunication.

13. Types of Care

[#.] Custodial Care.

[#.] Rest or domiciliary care.

[#.] All institutional charges over the semi-private room rate, except when a

private room is Medically Necessary.

[#.] Home health care services that extend beyond care on a short-term

intermittent basis.

[#.] Pain management programs or clinics.

[#.] Physical conditioning programs such as athletic training, body-building,

exercise, fitness, flexibility, and diversion or general motivation.

[#.] Private duty nursing.

[#.] Sports medicine clinics.

[#.] Vocational rehabilitation, or vocational evaluations on job adaptability, job

placement, or therapy to restore function for a specific occupation.

14. Vision and Hearing

[#.] Eyeglasses, contact lenses and fittings, except as listed in this Benefit

Handbook.

[#.]

Hearing aid batteries, cords, and individual or group auditory training device

and any instrument or device used by a public utility in providing telephone

or other communication services.

[#.] Refractive eye surgery, including, but not limited to, lasik surgery,

orthokeratology and lens implantation for the correction of myopia, hyperopia

and astigmatism.

(17)

[#.] Any service or supply furnished in connection with a non-Covered Benefit.

[#.] Beauty or barber service.

[#.] Any drug or other product obtained at an outpatient pharmacy, except for

pharmacy supplies covered under the benefit for diabetes services, unless your

Plan includes outpatient pharmacy coverage.

[#.] Food or nutritional supplements, including, but not limited to, FDA-approved

medical foods obtained by prescription, except as required by law.

[#.] Guest services.

[#.] Services for non-Members.

[#.] Services for which no charge would be made in the absence of insurance.

[#.] Services for which no coverage is provided in this Benefit Handbook[,][

or] Schedule of Benefits[ or Prescription Drug Brochure [(if your Plan includes

outpatient pharmacy coverage)]].

[#.] Services that are not Medically Necessary.

[#.] Taxes or governmental assessments on services or supplies.

[#.] Transportation other than by ambulance.

[#.] The following products and services:

•

Air conditioners, air purifiers and filters, dehumidifiers and humidifiers.

•

Car seats.

•

Chairs, bath chairs, feeding chairs, toddler chairs, chair lifts, recliners.

•

Electric scooters.

•

Exercise equipment.

•

Home modifications including but not limited to elevators, handrails and ramps.

•

Hot tubs, jacuzzis, saunas or whirlpools.

•

Mattresses.

•

Medical alert systems.

•

Motorized beds.

•

Pillows.

•

Power-operated vehicles.

•

Stair lifts and stair glides.

•

Strollers.

•

Safety equipment.

•

Vehicle modifications including but not limited to van lifts.

•

Telephone.

,